Provider Demographics
NPI:1568509966
Name:MILWAUKIE CONVALESCENT HOSPITAL INC
Entity Type:Organization
Organization Name:MILWAUKIE CONVALESCENT HOSPITAL INC
Other - Org Name:MILWAUKIE CONVALESCENT CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:GM
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:EIVERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-659-2323
Mailing Address - Street 1:12045 SE STANLEY AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKIE
Mailing Address - State:OR
Mailing Address - Zip Code:97222
Mailing Address - Country:US
Mailing Address - Phone:503-659-2323
Mailing Address - Fax:503-353-8533
Practice Address - Street 1:12045 SE STANLEY AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKIE
Practice Address - State:OR
Practice Address - Zip Code:97222
Practice Address - Country:US
Practice Address - Phone:503-659-2323
Practice Address - Fax:503-353-8533
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-01
Last Update Date:2015-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR313M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR802645Medicaid
OR802645Medicaid